Treatment of congenital adrenal hyperplasia

ABSTRACT

CRF1 receptor antagonists have the potential to directly inhibit ACTH release in patients with CAH and thereby allow normalization of androgen production while using lower, more physiologic doses of hydrocortisone, and thus reducing treatment-associated side effects.

RELATED APPLICATIONS

Any and all priority claims identified in the Application Data Sheet, orany correction thereto, are hereby incorporated by reference under 37C.F.R. § 1.57. This application is a continuation of U.S. patentapplication Ser. No. 17/074,845, filed on Oct. 20, 2020, which is acontinuation of U.S. patent application Ser. No. 16/227,127, filed onDec. 20, 2018, now issued U.S. Pat. No. 10,905,690, which is acontinuation of U.S. patent application Ser. No. 15/113,362, filed onJul. 21, 2016, which is the U.S. National Phase of InternationalApplication No. PCT/US2015/012315, filed on Jan. 21, 2015, which claimspriority to and the benefit of U.S. Provisional Application No.61/929,941, filed on Jan. 21, 2014; 61/981,033, filed on Apr. 17, 2014;and 62/069,155, filed on Oct. 27, 2014, the disclosures of which areeach incorporated herein by reference in their entireties.

TECHNICAL FIELD

Compositions and methods for treating congenital adrenal hyperplasia aredescribed herein.

BACKGROUND

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessivegenetic disorders that result in little or no cortisol biosynthesis. Themost frequent form of the disease is 21-hydroxylase deficiency caused bymutations in the CYP21A2 gene located on chromosome 6p21, which accountsfor approximately 95% of CAH cases (see, e.g., Speiser et al., Int. J.Pediatr. Endocrinol. 2010: 494173 (2010) for a review). These mutationscan range from complete loss of enzyme activity required for synthesisof cortisol in the adrenal cortex to a spectrum of partial loss, whichresults in disease severity that is a direct consequence of a specificmutation. This continuum of 21-hydroxylase deficiency has been broadlyclassified into salt-wasting and simple-virilizing forms, grouped asclassical CAH, and the milder form known as non-classic CAH (NCCAH) or“late-onset” CAH, which is usually diagnosed in late childhood or earlyadulthood. Non-classic CAH patients are either homozygous or compoundheterozygotes, often with a classical CAH allele. These patients havesufficient enzyme activity (>20-50% of normal) such that they do nothave salt-wasting or cortisol deficiency and have normal genitalia atbirth, and many remain asymptomatic throughout life (Trapp et al.,Steroids 77(4): 342-46 (2012)). In the less frequent form of thedisease, which accounts for 5% of cases, mutation of the 11β-hydroxylasegene CYP11B1 results in CAH (11β-OH CAH).

Both genetic mutations result in congenital adrenal hyperplasia,cortisol deficiency and excessive adrenocorticotropic hormone (ACTH)production with overproduction of androgens. These patients requirelifelong management with glucocorticoids and the attendant problemsassociated with such treatment. Accordingly, a significant need existsfor treatment regimens to improve the health, well-being, quality oflife, and to manage related disorders in patient with CAH.

SUMMARY

Corticotropin-releasing factor (CRF) activates the CRF₁ receptor, aclass B G protein-coupled receptor (GPCR). CRF₁ antagonists have thepotential to directly inhibit ACTH release in patients with CAH, therebyallowing normalization of androgen production while using lower, morephysiologic doses of hydrocortisone, and reducing treatment-associatedside effects.

In one embodiment, a method is provided for treating CAH byadministering to a subject in need thereof an effective amount of a CRF₁antagonist, including (but not limited to) bedtime administration.

In a more specific embodiment, the CRF₁ antagonist has a dissociationhalf-life (t_(1/2)) in excess of 30 minutes, and in another embodimentin excess of 40 minutes, and in another embodiment in excess of 50minutes.

Embodiment 1. A method for treating Congenital Adrenal Hyperplasia (CAH)by administering to a subject in need thereof a CRF₁ receptor antagonisthaving a dissociation half-life in excess of 30 minutes.

Embodiment 2. The method of Embodiment 1 wherein the CRF₁ receptorantagonist has a dissociation half-life in excess of 40 minutes.

Embodiment 3. The method of Embodiment 1 wherein the CRF₁ receptorantagonist has a dissociation half-life in excess of 50 minutes.

Embodiment 4. The method of any one of Embodiments 1-3 wherein the CRF₁receptor antagonist is Compound I (NBI-77860;2,5-dimethyl-3-[2-methyl-4-(methyloxy)phenyl]-N-[(1S)-1-(3-methyl-1,2,4-oxadiazol-5-yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine).

Embodiment 5. The method of any one of Embodiments 1-3 wherein the CRF₁receptor antagonist is NBI-30775, NBI-34041, SSR-126374, SSR-125543,antalarmin(N-butyl-N-ethyl-2,5,6-trimethyl-7-(2,4,6-trimethylphenyl)pyrrolo[3,2-e]pyrimidin-4-amine),or DMP904.

Embodiment 6. The method of any one of Embodiments 1-5 wherein the CRF₁receptor antagonist is administered at bedtime.

Embodiment 7. The method of any one of Embodiments 1-6 wherein the CRF₁receptor antagonist is administered at or before the expected circadianrelease of ACTH.

Embodiment 8. The method of Embodiment 7 wherein the CRF₁ receptorantagonist is administered 3-4 hours before the expected circadianrelease of ACTH.

Embodiment 9. A method for reducing 17-OHP and ACTH levels in a subjectwho has Congenital Adrenal Hyperplasia (CAH), said method comprisingadministering to the subject a CRF₁ receptor antagonist at bedtime.

Embodiment 10. The method of Embodiment 9, wherein the CRF₁ receptorantagonist is administered at or before the expected circadian releaseof ACTH.

Embodiment 11. The method of Embodiment 9 or Embodiment 10, wherein theCRF₁ receptor antagonist is administered 3-4 hours before the expectedcircadian release of ACTH.

Embodiment 12. The method of any one of Embodiments 9-11, wherein theCRF₁ receptor antagonist is Compound I (NBI-77860;2,5-dimethyl-3-[2-methyl-4-(methyloxy)phenyl]-N-[(1S)-1-(3-methyl-1,2,4-oxadiazol-5-yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine).

Embodiment 13. The method of any one of Embodiments 9-11, wherein theCRF₁ receptor antagonist is NBI-30775, NBI-34041, SSR-126374,SSR-125543, antalarmin(N-butyl-N-ethyl-2,5,6-trimethyl-7-(2,4,6-trimethylphenyl)pyrrolo[3,2-e]pyrimidin-4-amine),or DMP904.

Embodiment 14. A CRF₁ receptor antagonist for use in treating CongenitalAdrenal Hyperplasia (CAH), wherein the CRF₁ receptor antagonist has adissociation half-life in excess of 30 minutes.

Embodiment 15. The CRF₁ receptor antagonist of 14, wherein the CRF₁receptor antagonist has a dissociation half-life in excess of 40minutes.

Embodiment 16. The CRF₁ receptor antagonist of Embodiment 14, whereinthe CRF₁ receptor antagonist has a dissociation half-life in excess of50 minutes.

Embodiment 17. The CRF₁ receptor antagonist of any one of Embodiments14-16, wherein the CRF₁ receptor antagonist is Compound I (NBI-77860;2,5-dimethyl-3-[2-methyl-4-(methyloxy)phenyl]-N-[(1S)-1-(3-methyl-1,2,4-oxadiazol-5-yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine).

Embodiment 18. The CRF₁ receptor antagonist of any one of Embodiments14-16, wherein the CRF₁ receptor antagonist is NBI-30775, NBI-34041,SSR-126374, SSR-125543, antalarmin(N-butyl-N-ethyl-2,5,6-trimethyl-7-(2,4,6-trimethylphenyl)pyrrolo[3,2-e]pyrimidin-4-amine),or DMP904.

Embodiment 19. The CRF₁ receptor antagonist of any one of Embodiments14-18, wherein the CRF₁ receptor antagonist is suitable foradministration at bedtime.

Embodiment 20. The CRF₁ receptor antagonist of any one of Embodiments14-19, wherein the CRF₁ receptor antagonist is suitable foradministration at or before the expected circadian release of ACTH.

Embodiment 21. The CRF₁ receptor antagonist of any one of Embodiments14-20, wherein the CRF₁ receptor antagonist is suitable foradministration 3-4 hours before the expected circadian release of ACTH.

In other embodiments, the methods and uses described above and hereinfurther comprise reducing the amount of a glucocorticoid ormineralocorticoid by at least 10%, 15%, 20%, 30%, 40%, 50%, 60% from therecommended daily dose of GC (such as hydrocortisone (HC), prednisone,prednisolone, dexamethasone, or fludrocortisone) administered to a fullgrown subject (e.g., a human subject) who has CAH. In other embodiments,the methods and uses described above and herein further comprisereducing the amount of a glucocorticoid or mineralocorticoid by at least10%, 15%, 20%, 30%, 40%, 50%, 60% from the recommended daily dose of GC(e.g., hydrocortisone) or mineralocorticoid (e.g., fludrocortisone)administered to a growing subject (e.g., a human subject) who has CAH.

These and other embodiments will be apparent upon reference to thefollowing detailed description. To this end, various references are setforth herein that describe in more detail certain backgroundinformation, procedures, compounds and compositions, and are each herebyincorporated by reference in their entirety.

Terms not specifically defined herein should be given the meanings thatwould be given to them by one of skill in the art in light of thedisclosure and the context. As used in the specification, however,unless specified to the contrary, the terms have the meaning indicated.Reference throughout this specification to “one embodiment” or “anembodiment” means that a particular feature, structure or characteristicdescribed in connection with the embodiment is included in at least oneembodiment. Thus, the appearances of the phrases “in one embodiment” or“in an embodiment” in various places throughout this specification arenot necessarily all referring to the same embodiment. Furthermore, theparticular features, structures, or characteristics may be combined inany suitable manner in one or more embodiments.

Also, as used in this specification and the appended claims, thesingular forms “a,” an, and “the” include plural referents unless thecontent clearly dictates otherwise. Thus, for example, reference to “anon-human animal” may refer to one or more non-human animals, or aplurality of such animals, and reference to “a cell” or “the cell”includes reference to one or more cells and equivalents thereof (e.g.,plurality of cells) known to those skilled in the art, and so forth.When steps of a method are described or claimed, and the steps aredescribed as occurring in a particular order, the description of a firststep occurring (or being performed)“prior to” (i.e., before) a secondstep has the same meaning if rewritten to state that the second stepoccurs (or is performed) “subsequent” to the first step. The term“about” when referring to a number or a numerical range means that thenumber or numerical range referred to is an approximation withinexperimental variability (or within statistical experimental error), andthus the number or numerical range may vary between 1% and 15% of thestated number or numerical range. It should also be noted that the term“or” is generally employed in its sense including “and/or” unless thecontent clearly dictates otherwise. The term, “at least one,” forexample, when referring to at least one compound or to at least onecomposition, has the same meaning and understanding as the term, “one ormore.”

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a schematic of steroid synthetic pathways in the adrenalgland. The most common form of CAH is caused by 21-hydroxylase (alsocalled 21-α hydroxylase) deficiency resulting in a decrease of cortisoland increase in androgens such as testosterone and estrogen. A more raretype of classical CAH is 11p-hydroxylase deficiency.

FIG. 2 presents a graph illustrating the effect of Compound I(NBI-77860) on ACTH concentration in adrenalectomized rats. Ratsreceived 30 mg/kg of Compound I (NBI-77860) orally. Data are presentedas mean plasma concentration of ACTH (±SEM).

FIGS. 3A-C present graphs illustrating the effect of CRF₁ receptorantagonists, differentiated by their dissociation half-life, on ACTHconcentration in adrenalectomized rats.

FIG. 4 presents the study design schematic for the clinical trialdescribed in Example 6 that was designed to assess the safety,tolerability and plasma exposure of NBI-77860, as well as the effect ofthis compound on endogenous levels of HPA(hypothalamic-pituitary-adrenal) axis hormones.

FIG. 5 presents the data for mean 17-OHP (upper panel) and ACTH levels(lower panel) throughout the 24-hour postdose period for the clinicaltrial described in Example 6.

FIG. 6 presents the response of a specific individual subject for 17-OHP(upper panel) and ACTH levels (lower panel) following administration of300 mg and 600 mg NBI-77860 and placebo over time.

DETAILED DESCRIPTION

As described herein, CRF₁ receptor antagonists have been found todirectly inhibit ACTH release in patients with CAH and thereby allownormalization of androgen production.

Administration of a CRF₁ receptor antagonist permits use of lower, morephysiologic doses of hydrocortisone in subjects with CAH and thusreduces treatment-associated side effects.

Newborn screening for CAH is performed by immunoassay to measure 17-OHPlevels in heel-stick capillary blood specimens obtained within the first72 hours of life. The blood sample is analyzed for 17-OHP bycommercially available dissociation-enhanced lanthanidefluoroimmunoassay (DELFIA; PerkinElmer, Waltham Mass.) (White et al., J.Pediatr. 163:10-12 (2013)).

Second-tier screening tests utilizing biochemical and molecular genetictesting methods, performed between 8 and 14 days of life, are employedby nine states in the United States and strongly recommended by anadditional 5 states. The biochemical method includes immunoassay withorganic solvent extraction or liquid chromatography followed by tandemmass spectrometry to measure steroid ratios of 17-OHP, androstenedione,and 21-deoxycortisol to cortisol (see, e.g., Speiser et al., Int. J.Pediatr. Endocrinol. 2010: 494173, 2010). The genetic screen looks forCYP21A2 mutations that are associated with CAH. While not widelyemployed in the U.S., the addition of a second screening couldpotentially improve the sensitivity of the overall screening process,where sensitivity of the first screen alone is approximately 72%.

In absence of results from the newborn screening, female infants withclassical CAH are typically identified due to the presence of ambiguousgenitalia. Males have normal genitalia at birth and therefore are notdiagnosed unless newborn screening is conducted or other medicalcomplications come to attention. Infants who are not initially diagnosedwith CAH and suffer from the salt-wasting form of the disease are laterdiagnosed in the setting of poor weight gain, vomiting, hyperkalemia andhyponatremia within the first few weeks of life.

Treatment of CAH is based on normalization of hormone and steroid levelsusing a variety of medications from diagnosis in infancy throughadulthood. Glucocorticoids are the current standard treatment in CAH andare used both to correct the endogenous cortisol deficiency and forreducing the elevated ACTH levels from the pituitary, which drivesincreased androgen production. Unlike the treatment of Addison's disease(adrenal insufficiency), in which cortisol replacement is sufficient,the treatment of CAH must also reduce ACTH production, to control thesubsequent androgen excess as well. Thus, the goals of glucocorticoidtreatment include cortisol replacement and suppression of ACTH toprevent virilization and menstrual disturbances in women and to inhibittesticular adrenal rest tumors in men. Mineralocorticoid replacement isneeded to achieve normal plasma renin activity for maintenance ofregular blood pressure, electrolyte balance, and volume status in thosepatients with the salt-wasting form of CAH.

The regimen of glucocorticoid treatment must support normal physiologyand also ensure that sufficient cortisol is available during events thatmay elicit a strong stress response (e.g., intercurrent illness,exercise, hypotension). Careful monitoring is also necessary to avoidthe development of iatrogenic Cushing's syndrome due to glucocorticoidovertreatment in an effort to adequately suppress androgen production,or Addisonian syndrome due to under-treatment. Overtreatment withmineralocorticoids may cause hypertension while under-treatment may leadto low blood pressure, salt loss, fatigue and increased requirements forglucocorticoids. Typical laboratory tests for monitoring treatmentefficacy include measurement of plasma concentrations of 17-OHP,androstenedione, testosterone, renin activity, and electrolytes.

Adult patients with CAH have an increased prevalence of risk factors forcardiovascular disease including obesity, hypertension, and insulinresistance (see, e.g., Kim et al., Semin. Reprod. Med. 27(4): 316-21(2009)). A study of a large cohort of pediatric and adult CAH patients(n=244) demonstrated that patients are prescribed a variety ofglucocorticoid treatment regimens yet frequently suffer from poorhormonal control and the aforementioned adverse outcomes (see, e.g.,Finkielstain et al., J. Clin. Endocrinol Metab. 97(12): 4429-38 (2012)).

Treatment of CAH includes efforts to normalize the cortisol deficiencywith glucocorticoids (usually hydrocortisone in children but often morepotent agents with narrow therapeutic indices, such as dexamethasone, inadults) and, if necessary for salt-wasting, mineralocorticoids (usuallyfludrocortisone). The glucocorticoid doses required to achievesufficient suppression of excess androgens, however, are usually wellabove the normal physiologic dose used for cortisol replacement alone asin patients with Addison's disease. This increased exposure toglucocorticoids can lead to iatrogenic Cushing's syndrome, increasedcardiovascular risk factors, glucose intolerance, and decreased bonemineral density in CAH patients (see, e.g., Elnecave et al., J. Pediatr.Endocrinol. Metab. 21:1155-62 (2008); King et al., J. Clin. Endocrinol.Metab. 91(3): 8656-59 (2006); Migeon et al., Endocrinol. Metab. Clin.North Am. 30:193-206 (2001)).

Corticotropin-releasing factor (CRF) was isolated from ovine hypothalamiand identified as a 41-amino acid peptide. CRF has been found to produceprofound alterations in endocrine, nervous, and immune system function.CRF is believed to be the major physiological regulator of the basal andstress-induced release of adrenocorticotropic hormone (“ACTH”),B-endorphin, and other pro-opiomelanocortin (“POMC”)-derived peptidesfrom the anterior pituitary (see, e.g., Vale et al., Science213:1394-1397, 1981). Secretion of CRF causes release of ACTH fromcorticotrophs in the anterior pituitary via binding to the CRF₁receptor, a member of the class B family of G-protein coupled receptors.

Due to the physiological significance of CRF, the development ofbiologically-active small molecules having significant CRF₁ receptorbinding activity and which are capable of antagonizing the CRF₁ receptorremains a desirable goal and has been the subject of ongoing researchand development for the treatment of anxiety, depression, irritablebowel syndrome, post-traumatic stress disorder, and substance abuse.

The pituitary hormone ACTH, under the control of hypothalamiccorticotropin-releasing factor (CRF), stimulates uptake of cholesteroland drives the synthesis of pregnenolone initiating steroidogenesis inthe adrenal gland (see FIG. 1). The adrenal cortex is comprised of threezones, which produce distinct classes of hormones many of which aredriven by ACTH mobilizing cholesterol through this pathway. Deficienciesin these enzymes as a result of mutation or deletion cause the substrateconcentrations to increase. In the most common form of CAH resultingfrom mutations or deletions in the 21-hydroxylase gene (CYP21A2), potentandrogens are produced by the adrenal because of the accumulation of thesteroid precursors, progesterone and 17-hydroxyprogesterone (17-OHP).Plasma levels of 17-OHP can reach 10-1000 times the normal concentrationin these cases. These increases result in the overproduction ofandrogens, specifically androstenedione, testosterone, anddihydroxytestosterone causing virilization in females. In addition,21-hydroxylase deficiency in CAH causes insufficient biosynthesis ofglucocorticoids and mineralocorticoids, specifically cortisol andaldosterone. Cortisol is a critical negative feedback regulator ofhypothalamic CRF secretion and pituitary ACTH release. The lack ofglucocorticoid synthesis and release eliminates the restraint on thehypothalamus and pituitary, which causes ACTH levels to increase. Theexcessive ACTH stimulation causes hypertrophy of the zona fasciculataand zona reticularis resulting in adrenal hyperplasia.

In an embodiment, a CRF₁ receptor antagonist useful for the treatment ofCAH is NBI-77860,2,5-dimethyl-3-[2-methyl-4-(methyloxy)phenyl]-N-[(1S)-1-(3-methyl-1,2,4-oxadiazol-5-yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine(also referred to as “Compound I” herein), and which has the followingstructure.

Compound I is a potent CRF₁ antagonist possessing a binding pKi=8.2(see, e.g., Tellew et al., Boorg. Med. Chem. Lett. 20:7259, 2010 andInt'l. Patent Appl. Publ. No. WO 2006/044958, both of which referencesare incorporated by reference herein in their entirety). As describedherein, Compound I has potent ACTH lowering effects as shown inadrenalectomized rats.

In another embodiment, the CRF₁ receptor antagonist useful for thetreatment of CAH is a small molecule antagonist as described in U.S.Pat. Nos. 6,586,456, 6,806,282, 6,531,475, 6,664,261, 6,610,678, WO98/08846, WO 98/11075, WO 99/10350, WO 2000/059888, WO 2006/044821, WO2006/102194, WO 2006/107784, WO 2006/116412, WO 2006/126718, WO2007/069565, WO 2007/069671, WO 2008/036541, WO 2008/036579, WO2008/051533, WO 2008/082003, WO 2008/083070, WO 2008/136377, WO2009/008552, WO 2009/144632, WO 2010/014280, WO 2010/014687, WO2010/015628, WO 2010/015655, WO 2010/062718, WO 2010/096426, WO2011/043387, WO 2011/092293, WO 2011/095450, WO 2011/092290, and WO2011/043381.

In still another embodiment, the CRF₁ receptor antagonist is NBI-30775,CP-316,311, pexacerfont, emicerfont, SSR-125543[4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine],SSR-126374, ONO-2333, NBI-34041, JNJ-19567470, GSK586529, PF-00572778,CP-376395, antalarmin(N-butyl-N-ethyl-2,5,6-trimethyl-7-(2,4,6-trimethylphenyl)pyrrolo[3,2-e]pyrimidin-4-amine),and DMP904.

In yet another embodiment, the CRF₁ receptor antagonist has adissociation half-life (t_(1/2)) in excess of 30 minutes, and in anotherembodiment in excess of 40 minutes, and in another embodiment in excessof 50 minutes. The dissociation half-life of a particular CRF₁ receptorantagonist is determined by the technique disclosed in Example 3.Representative CRF₁ receptor antagonists of these embodiments includeCompound I, NBI-30775, NBI-34041, SSR-125543A, antalarmin(N-butyl-N-ethyl-2,5,6-trimethyl-7-(2,4,6-trimethylphenyl)pyrrolo[3,2-e]pyrimidin-4-amine),and DMP904.

With respect to the compounds described herein, it should also beunderstood that when a particular position is designated as hydrogen,that such hydrogen (H) may be replaced with deuterium (D). Incorporationof deuterium in place of hydrogen is known to produce significanteffects on the physiological and pharmacological activities of thesubstituted compound. To this end, it should be understood thatdeuterium replacement of hydrogen means that the abundance of deuteriumat that position is substantially greater than the natural abundance ofdeuterium. Accordingly, in one embodiment representative compoundsinclude the following.

Cpd. Structure Chemical Name NBI-77860

2,5-dimethyl-3-[2- methyl-4- (methyloxy)phenyl]-N-[(1S)-1-(3-methyl-1,2,4- oxadiazol-5- yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine Deuterated NBI-77860

2,5-dimethyl-3-[2- methyl-4-(d₃- methyloxy)phenyl]-N-[(1S)-1-(3-methyl-1,2,4- oxadiazol-5- yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine Deuterated NBI-77860

2,5-dimethyl-3-[2- methyl-4- (methyloxy)phenyl]-N- [(1S)-1-(3-d₃-methyl-1,2,4-oxadiazol-5- yl)propyl]pyrazolo[1,5- a]pyrimidin-7-amineDeuterated NBI-77860

2,5-dimethyl-3-[2- methyl-4-(d₃- methyloxy)phenyl]-N-[(1S)-1-(3-d₃-methyl- 1,2,4-oxadiazol-5- yl)propyl]pyrazolo[1,5-a]pyrimidin-7-amine Deuterated NBI-77860

R₁-R₂₆ independently H or D SSR-125543

4-(2-chloro-4-methoxy- 5-methylphenyl)-N- [(1S)-2-cyclopropyl-1-(3-fluoro-4- methylphenyl)ethyl]-5- methyl-N-(2-propyn-1-yl)-2-thiazolamine Deuterated SSR-125543

R₁-R₂₇ independently H or D NBI-30775

5-[7-(dipropylamino)- 2,5- dimethylpyrazolo[1,5- a]pyrimidin-3-yl]-N,N,4-trimethylpyridin- 2-amine Deuterated NBI-30775

R₁-R₃₂ independently H or D NBI-34041

3-(2,4-dichlorophenyl)- 9-(heptan-4-yl)-6- methyl-1,2,5,9-tetraazatricyclo[6.3.1.0^(4,12)] dodeca-2,4(12),5,7- tetraene DeuteratedNBI-34041

R₁-R₂₆ independently H or D Pexacerfont

N-[(2R)-butan-2-yl]-8- (6-methoxy-2- methylpyridin-3-yl)-2,7-dimethylpyrazolo[1,5- a][1,3,5]triazin-4-amine Deuterated Pexacerfont

R₁-R₂₄ independently H or D CP-316,311

3,6-dimethyl-4-(pentan- 3-yloxy)-2-(2,4,6- trimethylphenoxy) pyridineDeuterated CP-316,311

R₁-R₂₉ independently H or D GSK876008

Deuterated GSK876008

R₁-R₂₂ independently H or D CRA5626/ R317573

Deuterated CRA5626/ R317573

R₁-R₂₄ independently H or D ONO2333Ms

10-(2-chloro-4- methoxyphenyl)-11- methyl-N-(pentan-3- yl)-1,8,12-triazatricyclo[7.3.0.0^(3,7)] dodeca-2,7,9,11- tetraen-2-amineDeuterated ONO2333

R₁-R₂₇ independently H or D NBI76169

Deuterated NBI76169

R₁-R₂₂ independently H or D

In another embodiment, any of the aforementioned compounds mayincorporate stable or radioactive isotopes. Accordingly, alsocontemplated is use of isotopically-labeled compounds identical to thosedescribed herein, wherein one or more atoms are replaced by an atomhaving an atomic mass or mass number different from the atomic mass ormass number usually found in nature. Examples of isotopes that can beincorporated into these compounds include isotopes of hydrogen, carbon,nitrogen, oxygen, phosphorous, fluorine and chlorine, such as, but notlimited to deuterium as discussed above (2H), as well as 3H, 13C, 14C,15N, 18O, 17O, 31P, 32P, 35S, 18F, and 36Cl, respectively. Certainisotopically-labeled compounds, for example those into which radioactiveisotopes such as 3H and 14C are incorporated, are also useful in drug orsubstrate tissue distribution assays. Tritiated hydrogen (3H) andcarbon-14 (14C) isotopes are particularly preferred for their ease ofpreparation and detectability. Substitution with heavier isotopes suchas deuterium (2H) can provide certain therapeutic advantages resultingfrom greater metabolic stability, for example increased in vivohalf-life or reduced dose requirements and, therefore, may be preferredin some circumstances. Isotopically-labeled compounds can generally beprepared by performing procedures routinely practiced in the art.

Effect on Plasma ACTH in Adrenalectomized Rats

Adrenalectomy eliminates circulating corticosterone (the primaryglucocorticoid) in rats and removes the negative feedback control of theHPA axis at both the hypothalamic and pituitary (corticotroph cells)levels and thus chronically elevates plasma ACTH (see, e.g., Mims etal., J. Natl. Med. Assoc. 69:145-47 (1977)). Intravenous injection ofpeptide CRF₁ receptor antagonists have been demonstrated to reduce thehigh plasma ACTH levels in adrenalectomized (ADX) rats (see, e.g.,Rivier et al., J. Med. Chem. 12:42:3175-82 (1999)). These findings wererecapitulated with the small molecule NBI-77860 (Compound I). Inadrenalectomized rats, Compound I has potent capability for loweringACTH. The maximum reduction in ACTH correlated with peak plasmaconcentrations of NBI-77860; however, the duration of the ACTH-loweringeffect exceeded drug plasma exposure. In adrenalectomized rats, apredictable relationship therefore exists between integrated plasmaexposure of NBI-77860 and in vivo efficacy following oraladministration.

The effectiveness of a compound as a CRF receptor antagonist may bedetermined by various assay methods. CRF antagonists described hereinmay be capable of inhibiting the specific binding of CRF to its receptorand consequently antagonizing activities associated with CRF. A compoundmay be assessed for activity as a CRF antagonist by one or moregenerally accepted assays including the assay described in the Examples.CRF antagonists useful for the methods described herein includecompounds that demonstrate affinity for CRF receptor.

Without wishing to be bound by theory, in the treatment of CAH, CRFreceptor antagonists would potentially block the release of ACTH frompituitary corticotrophs, thereby decreasing the production of androgens,and allow a more refined treatment paradigm for replacement of cortisol.

Animal and human studies have shown the pharmacologic effect of CompoundI (NBI-77860) on ACTH release. Standard biomarker assessments used byendocrinologists when monitoring treatment efficacy may be used formonitoring the effects of this CRF₁ receptor antagonist. Plasma levelsof 17-OHP, androstenedione, testosterone, cortisol and ACTH, as well asurinary metabolites of these steroids, are easily measured in bothchildren and adults giving rapid and meaningful data regarding treatmentimpact.

Pharmaceutical Compositions and Methods of Treatment

The present disclosure further provides for pharmaceutical compositionscomprising any one of the CRF antagonist compounds described herein anda pharmaceutically acceptable excipient for use in the methods fortreating CAH. A pharmaceutically acceptable excipient is aphysiologically and pharmaceutically suitable non-toxic and inactivematerial or ingredient that does not interfere with the activity of theactive ingredient; an excipient also may be called a carrier. The CRFantagonist compounds may be formulated in a pharmaceutical compositionfor use in treatment or preventive (or prophylactic) treatment (e.g.,reducing exacerbation of CAH disease, or occurrence or recurrence of oneor more symptoms of the disease). The methods and excipients describedherein are exemplary and are in no way limiting. Pharmaceuticallyacceptable excipients are well known in the pharmaceutical art anddescribed, for example, in Rowe et al., Handbook of PharmaceuticalExcipients: A Comprehensive Guide to Uses, Properties, and Safety,5^(th) Ed., 2006, and in Remington: The Science and Practice of Pharmacy(Gennaro, 21^(st) Ed. Mack Pub. Co., Easton, Pa. (2005)). Examples ofpharmaceutically acceptable excipients include sterile saline andphosphate buffered saline at physiological pH. Preservatives,stabilizers, dyes, buffers, and the like may be provided in thepharmaceutical composition. In addition, antioxidants and suspendingagents may also be used.

Therapeutic and/or prophylactic benefit includes, for example, animproved clinical outcome, both therapeutic treatment and prophylacticor preventative measures, wherein the object is to prevent or slow orretard (lessen) an undesired physiological change or disorder, or toprevent or slow or retard (lessen) the expansion or severity of suchdisorder. As discussed herein, beneficial or desired clinical resultsfrom treating a subject include, but are not limited to, abatement,lessening, or alleviation of symptoms that result from or are associatedthe disease, condition, or disorder to be treated; decreased occurrenceof symptoms; improved quality of life; longer disease-free status (i.e.,decreasing the likelihood or the propensity that a subject will presentsymptoms on the basis of which a diagnosis of a disease is made);diminishment of extent of disease; stabilized (i.e., not worsening)state of disease; delay or slowing of disease progression; ameliorationor palliation of the disease state; and remission (whether partial ortotal), whether detectable or undetectable; and/or overall survival.“Treatment” can also mean prolonging survival when compared to expectedsurvival if a subject were not receiving treatment. Subjects in need oftreatment include those who already have the condition or disorder aswell as subjects prone to have or at risk of developing the disease,condition, or disorder, and those in which the disease, condition, ordisorder is to be prevented (i.e., decreasing the likelihood ofoccurrence of the disease, disorder, or condition). A subject may be ahuman or non-human mammal (e.g., rat, mouse, dog, cat, livestock, zooanimal).

Optimal doses may generally be determined using experimental modelsand/or clinical trials. The optimal dose may depend upon the body mass,weight, or blood volume of the subject. In general, the amount of acompound described herein, that is present in a dose ranges from about0.1 mg to about 30 mg per kg weight of the subject. In certainembodiments, a single dose is about 50-1000 mg. The use of the minimumdose that is sufficient to provide effective therapy is usuallypreferred. Subjects may generally be monitored for therapeuticeffectiveness by clinical evaluation and using assays suitable for thecondition being treated or prevented, which assays will be familiar tothose having ordinary skill in the art and are described herein. Thelevel of a compound that is administered to a subject may be monitoredby determining the level of the compound in a biological fluid, forexample, in the blood, blood fraction (e.g., serum), and/or in theurine, and/or other biological sample from the subject. Any methodpracticed in the art to detect the compound may be used to measure thelevel of compound during the course of a therapeutic regimen.

The dose of a composition comprising at least one of the compoundsdescribed herein for treating CAH or a related disease or disorder maydepend upon the subject's condition, that is, stage of the disease,severity of symptoms caused by the disease, general health status, aswell as age, gender, and weight, and other factors apparent to a personskilled in the medical art. Similarly, the dose of the compound may bedetermined according to parameters understood by a person skilled in themedical art.

The pharmaceutical compositions described herein that comprise at leastone of the CRF₁ antagonist compounds described herein may beadministered to a subject in need by any one of several routes thateffectively deliver an effective amount of the compound. Suchadministrative routes include, for example, oral, parenteral, enteral,rectal, intranasal, buccal, sublingual, intramuscular, and transdermal.Compositions administered by these routes of administration and othersare described in greater detail herein.

Administration of the compounds or compositions disclosed includesnighttime administration or administration prior to sleep (i.e., bedtimeadministration). As used herein, bedtime administration refers to dosingintended to deliver clinically relevant concentrations of the CRF₁antagonist at or before (such as 2-5 hours before) the expectedcircadian release of ACTH. Since this ACTH release is typically at 1-2A.M., and since most orally administered drugs have a Tmax of severalhours, dosing at 10 P.M., for example, which is 3-4 hours in advance ofthe expected circadian release of ACTH is desirable. This same pre-pulsebedtime dosing may be adapted for shift workers (e.g., those who work atnight and sleep during the day), in which case administration will notnecessarily occur at nighttime. Administration is therefore dependentupon the expected circadian release of ACTH, and can vary depending uponthe individual's (i.e., subject, patient) particular work and sleeppatterns. In certain embodiments, a CRF₁ receptor antagonist describedherein (for example, NBI-77860 or any one of NBI-30775, NBI-34041,SSR-126374, SSR-125543, antalarmin(N-butyl-N-ethyl-2,5,6-trimethyl-7-(2,4,6-trimethylphenyl)pyrrolo[3,2-e]pyrimidin-4-amine),or DMP904) is administered between about 2-5 hours prior to (i.e.,before, in advance of) the expected circadian release of ACTH. In otherembodiments, the CRF₁ receptor antagonist is administered to the subjectbetween about 2-4 hours or 3-5 hours prior to the expected circadianrelease of ACTH. In a more specific embodiment, CRF₁ receptor antagonistis administered to the subject between about 3-4 hours prior to theexpected circadian release of ACTH.

Also provided herein is a method for reducing 17-OHP and/or ACTH levelsin a subject (i.e., patient, individual) who has CAH by administering aCRF₁ receptor antagonist. In certain embodiments, the antagonist isadministered at or before the expected circadian release of ACTH. Inother certain embodiments, the CRF₁ receptor antagonist as administeredbetween about 2-4 hours or between about 3-5 hours prior to the expectedcircadian release of ACTH. In a more specific embodiment, CRF₁ receptorantagonist is administered to the subject between about 3-4 hours priorto the expected circadian release of ACTH.

The methods described herein that comprise administering a CRF₁ receptorantagonist to a female subject in need thereof in the manner describedherein that causes a decrease in level of ACTH and 17-OHP in the subjectmay result in decreased release of androgens such as testosterone andandrostenedione. The dose of glucocorticoids may concomitantly bedecreased by a clinically significant amount, which in turn results indecreased side effects.

The amount of glucocorticoids (GC) and mineralocorticoids (MC) formaintenance therapy in patients who have CAH and who are young andgrowing and for maintenance therapy in patients who are full grownpatients is known to a person skilled in the art. For example,guidelines are described in Speiser et al. (J. Clin. Endocrinol. Metab.95:4133-60 (2010), incorporated by reference in its entirety) and shownin the Tables 1 and 2 therein. Particularly, for young, growing patientswho have CAH, persons skilled in the art appreciate that too high dosingwith GCs can impede statural growth in the patient. Accordingly, themethods described herein for treating a patient with a CRF₁ receptorantagonist may comprise reducing the dose of a GC in a clinicallysignificant manner.

In certain embodiments, methods for treating CAH by administering a CRF₁receptor antagonist may further comprise administering a GC at a doselower than the currently recommended dose of a GC for treating a subjectwho has CAH. When the subject is a fully grown patient, the dose of aGC, such as the dose of hydrocortisone (HC), prednisone, prednisolone,dexamethasone, or fludrocortisone recommended for maintenance therapy ina fully grown subject may be decreased by about 10%, 15%, 20%, 30%, 40%,50%, 60% or more from the recommended doses of 15-25 mg/day HC; 5-7.5mg/day prednisone, 4-6 mg/day prednisolone; 0.25-0.5 mg/daydexamethasone, or 0.05-0.2 mg/day of fludrocortisone. In a subject whois a growing patient with CAH, the recommended dose of GCs, such as HCmay be decreased from the total recommended dose of 10-15 mg/M² per dayand/or the total dose of fludrocortisone of 0.05-0.2 mg/day may each bedecreased by about 10%, 15%, 20%, 30%, 40%, 50%, 60% or more in asubject who receives a CRF₁ receptor antagonist as described herein. Inan embodiment, the methods described herein comprising administering toa subject in need thereof an effective amount of a CRF₁ antagonistresults in a clinically significant reduction of ACTH levels relative toplacebo. In a specific embodiment, administering to a subject in needthereof an effective amount of a CRF₁ antagonist results in a clinicallysignificant reduction of ACTH levels relative to placebo, wherein thatreduction is at least 25%. In another embodiment, administering to asubject in need thereof an effective amount of a CRF₁ antagonist resultsin a clinically significant reduction of ACTH levels relative toplacebo, wherein that reduction is at least 50%. See Speiser et al.,supra, for guidelines regarding administering glucocorticoids andmineralocorticoids.

In another embodiment, the methods described herein comprisingadministering to a subject in need thereof an effective amount of a CRF₁antagonist results in a clinically significant reduction of 17-OHPlevels relative to placebo. In another specific embodiment,administering to a subject in need thereof an effective amount of a CRF₁antagonist results in a clinically significant reduction of 17-OHPlevels relative to placebo wherein that reduction is at least 25%. Instill another embodiment, administering to a subject in need thereof aneffective amount of a CRF₁ antagonist results in a clinicallysignificant reduction of 17-OHP levels relative to placebo wherein thatreduction is at least 50%.

In an embodiment, the methods described herein comprising administeringto a subject in need thereof an effective amount of a CRF₁ antagonistresults in a clinically significant reduction of both ACTH and 17-OHPlevels relative to placebo. In a certain embodiment, administering to asubject in need thereof an effective amount of a CRF₁ antagonist resultsin a clinically significant reduction of both ACTH and 17-OHP levelsrelative to placebo wherein the reduction is at least 25%. In anotherspecific embodiment, administering to a subject in need thereof aneffective amount of a CRF₁ antagonist results in a clinicallysignificant reduction of both ACTH and 17-OHP levels relative to placebowherein the reduction is at least 50%.

The pharmaceutical compositions may be in the form of a solution.Alternatively, they may be in the form of a solid, such as powder,tablets, or the like. A composition comprising any one of the compoundsdescribed herein may be formulated for sustained or slow release. Suchcompositions may generally be prepared using well known technology andadministered by, for example, oral, rectal or subcutaneous implantation,or by implantation at the desired target site. Sustained-releaseformulations may contain the compound dispersed in a carrier matrixand/or contained within a reservoir surrounded by a rate controllingmembrane. Excipients for use within such formulations are biocompatible,and may also be biodegradable; preferably the formulation provides arelatively constant level of active component release. The amount ofactive compound contained within a sustained release formulation dependsupon the site of implantation, the rate and expected duration ofrelease, and the nature of the condition to be treated or prevented.

For oral formulations, at least one of the compounds described hereincan be used alone or in combination with appropriate additives to maketablets, powders, granules or capsules, for example, with conventionaladditives, such as lactose, mannitol, corn starch or potato starch; withbinders; with disintegrators; with lubricants; and if desired, withdiluents, buffering agents, moistening agents, preservatives, coloringagents, and flavoring agents. The compounds may be formulated with abuffering agent to provide for protection of the compound from low pH ofthe gastric environment and/or an enteric coating. A compound includedin the compositions may be formulated for oral delivery with a flavoringagent, e.g., in a liquid, solid or semi-solid formulation and/or with anenteric coating. Oral formulations may be provided as gelatin capsules,which may contain the active compound along with powdered carriers, suchas lactose, starch, cellulose derivatives, magnesium stearate, stearicacid, and the like. Similar carriers and diluents may be used to makecompressed tablets.

EXAMPLES Example 1 CRF Receptor Binding Activity

CRF antagonists as used in the methods described herein may be evaluatedfor binding activity to the CRF receptor by a standard radioligandbinding assay as generally described by Grigoriadis et al. (see, e.g.,Mol. Pharmacol vol 50, pp 679-686, 1996) and Hoare et al. (see, e.g.,Mol. Pharmacol 63: 751-765, 2003.) By utilizing radiolabeled CRFligands, the assay may be used to evaluate the binding activity of thecompounds described herein with any CRF receptor subtype.

Briefly, the binding assay involves the displacement of a radiolabeledCRF ligand from the CRF receptor. More specifically, the binding assayis performed in 96-well assay plates using 1-10 μg cell membranes fromcells stably transfected with human CRF receptors. Each well receivesabout 0.05 mL assay buffer (e.g., Dulbecco's phosphate buffered saline,10 mM magnesium chloride, 2 mM EGTA) containing compound of interest ora reference ligand (for example, sauvagine, urocortin I, or CRF), 0.05mL of [¹²⁵I] tyrosine—sauvagine (final concentration ˜150 pM orapproximately the K_(D) as determined by Scatchard analysis) and 0.1 mLof a cell membrane suspension containing the CRF receptor. The mixtureis incubated for 2 hours at 22° C. followed by separation of the boundand free radioligand by rapid filtration over glass fiber filters.Following three washes, the filters are dried and radioactivity (Augerelectrons from ¹²⁵I) is counted using a scintillation counter. Allradioligand binding data may be analyzed using the non-linearleast-squares curve-fitting programs Prism (GraphPad Software Inc) orXLfit (ID Business Solutions Ltd).

Example 2 CRF₁ Receptor Agonist Activity

As reported in Fleck et al. (J. Pharmacology and ExperimentalTherapeutics, 341(2):518-531, 2012) (hereinafter “Fleck et al.” andincorporated by reference in it's entirely) the activity of previouslyidentified CRF₁ receptor antagonists are presented. Such activity isreported as the kinetically derived affinity (K_(i)) calculated from theassociation (k₁) and dissociation (k⁻¹) rate constants by the followingequation:K _(i) =k ⁻¹ /k ₁

Also as reported in Fleck et al., the kinetic K_(i) of the CRF₁ receptorantagonists listed in Table 1 below have been reported:

TABLE 1 Representative CRF₁ Receptor Antagonists k₁ Kinetic K_(i) Ligand(10⁶M⁻¹min⁻¹) (nM) NBI-27914 9.4 ± 3   25 CP-316,311 13 ± 2  12NBI-46200 6.2 ± 2   22 DMP696 7.7 ± 2   9.5 pexacerfont 2.6 ± 0.1 19NBI-35965 20 ± 2  2.3 ONO-2333Ms 4.4 ± 2.2 15 antalarmin 3.4 ± 0.6 3.9NBI-34041 8.3 ± 2.0 1.7 DMP904 18 ± 1  0.38 NBI-30775  14 ± 2.0 0.36SSR125543A 33 ± 5  0.049 NBI-77860 0.24 ± 0.05 48 ± 9

By this same technique, the kinetic K_(i) of Compound I (NBI-77860) wasfound to be as follows:

Example 3 Dissociation Half-Life (T_(1/2)) of CRF₁ Receptor Antagonists

The dissociation half-life (t_(1/2)) of a CRF₁ receptor antagonist asused in the methods described herein is evaluated by the techniquedescribed in Fleck et al. As described therein, the dissociation rateconstant for labeled and unlabeled ligands is denoted as k⁻¹, while thehalf-life of drug dissociation from the receptor (t_(1/2)), which isequal to the median residence time, is calculated from the dissociationrate constant (k⁻¹) by the following equation:t _(1/2)=0.693/k ⁻¹

As reported in Fleck et al., the dissociation half-life (t_(1/2)) of theCRF₁ receptor antagonists listed in Table 2 below have been reported.

TABLE 2 Dissociation Half-Life of Representative Compounds k₁Dissociation t_(1/2) Ligand (min⁻¹) (min) NBI 27914 0.27 ± 0.07 2.6CP-316,311 0.17 ± 0.04 4.1 NBI-46200  0.13 ± 0.002 5.3 DMP696 0.095 ±0.02  7.3 pexacerfont 0.049 ± 0.001 14 NBI-35965 0.048 ± 0.005 16ONO-2333Ms 0.063 ± 0.029 17 antalarmin 0.013 ± 0.002 53 NBI-34041 0.013± 0.002 53 DMP904 0.0072 ± 0.002  96 NBI-30775 0.0054 ± 0.0006 130SSR125543A 0.0016 ± 0.0003 430 NBI-77860  0.012 ± 0.0003 58

By this same technique, the dissociation half-life of Compound I(NBI-77860) was found to be as follows.

Accordingly, CRF₁ receptor antagonists that have a dissociationhalf-life (t_(1/2)) in excess of 30 minutes include (but are not limitedto) antalarmin, NBI-34041, DMP904, NBI-30775, SSR125543A, and NBI-77860(Compound I). These same compounds are also representative of CRF₁receptor antagonists having a dissociation half-life (t_(1/2)) in excessof 40 minutes, and a dissociation half-life (t_(1/2)) in excess of 50minutes.

Example 4 Lowering of ACTH in Adrenalectomized Rats

Compound I (NBI-77860)(see, e.g., Tellew et al., Boorg. Med. Chem. Lett.2010, 20:7259; WO2006044958) is a potent CRF₁ antagonist possessing abinding pKi of 8.2, a kinetic Ki of 49 nM (Table 1 above), and aDissociation t_(1/2) of 58 minutes (Table 2 above).

Intravenous injection of peptide CRF₁ receptor antagonists have beendemonstrated to reduce the high plasma ACTH levels in adrenalectomized(ADX) rats (see, e.g., Rivier et al., J. Med. Chem. 12:42:3175-82(1999)). These findings were recapitulated with the small moleculeNBI-77860. When administered orally to ADX rats (n=6/group), 30 mg/kgsingle doses of NBI-77860 significantly lowered the plasma ACTH levelsfor up to 5 hours (see FIG. 2). The duration of efficacy correlated withpeak plasma concentrations, with a time course exceeding drug plasmaexposure. In adrenalectomized rats, a predictable relationship existsbetween integrated plasma exposure of NBI-77860 and in vivo efficacyfollowing oral administration.

Fleck et al. also report the effects of CRF₁ receptor antagonistsdifferentiated by their dissociation half-life on plasma ACTH levels inadrenalectomized rats; namely, NBI 30775, NBI 34041 and NBI 35965. Atthe highest dose (10 mg/kg), all three ligands reduced ACTH acutely (1hr post-injection, FIG. 3A-C). After a longer duration, a cleardifference emerged between NBI 35965 and the other two ligands. The ACTHlevel returned to the vehicle level by 2 hr for NBI 35965 (FIG. 3C),whereas the response was sustained for 4-6 hr for NBI 30775 and NBI34041 (FIGS. 3A and 3B).

Example 5 Pharmacodynamic Effects of Compound I in Humans

In this study, pharmacodynamic effects of NBI-77860 (Compound I) onhuman subjects were evaluated by observing the effect of single oraldoses on HPA axis response produced by metyrapone (0.04 g/kg) withrespect to placebo and to a single dose of alprazolam (0.75 mg).Metyrapone blocks cortisol synthesis in the adrenal, thereby mimickingthe cortisol deficiency of CAH, and is associated with an acute reflexrise ACTH levels.

The primary analysis was performed by determining the ACTH valuesbetween 30 min and 4 h post dose (AUC (30 min to 4 h)). In thisanalysis, when compared to placebo, the following observations weremade. A significant reduction of ACTH AUC (30 min to 4 h) was observedwith the alprazolam and the NBI-77860, 400 mg treatments. Anon-significant reduction in ACTH AUC (30 min to 4 h) was seen with theNBI-77860, 50 mg treatment. An increase in AUC (30 min to 4 h) was seenwith the NBI-77860, 10 mg treatment.

In the analysis performed on the ACTH values between 2 h to 4 hpost-dose (AUC (2 h to 4 h))(the period when exposure reached theC_(max) value), there was a significant reduction of ACTH levels in theNBI-77860, 400 mg and 50 mg treatment periods compared with the placebotreatment period; however, the reduction was not seen with the NBI-77860at the 10 mg dose.

Example 6 Clinical Study

In this study, NBI-77860 (Compound I) was evaluated in the clinicalstudy entitled “A Phase 1, Single-Blind, Placebo-Controlled,Fixed-Sequence, Single-Dose Study to Evaluate the Safety andTolerability of NBI-77860 in Adult Females with Congenital AdrenalHyperplasia” (IND 117,388). The study was a single-blind,placebo-controlled, single center, fixed-sequence, single-dose clinicaltrial in adult female classical CAH patients. It was designed to assessthe safety, tolerability, and plasma exposure of NBI-77860, as well asthe effect of this compound on endogenous levels of HPA axis hormones.

A total of 8 female subjects, ages 19 to 58, with a medical diagnosis ofclassical 21-hydroxylase deficiency CAH were administered single bedtimedoses (hs) of NBI-77860 300 mg, 600 mg, and placebo during threeseparate treatment periods (see study design schematic in FIG. 4). Thesubjects' usual morning dose of concurrent steroidal treatment wasdelayed until after the 16-hour postdose blood samples were collected(i.e., until approximately 1400 h).

The PD endpoints for this study included the HPA axis biomarkers ofinterest in this patient population; namely, 17-hydroxyprogesterone(17-OHP; as the primary PD endpoint), adrenocorticotropic hormone(ACTH), androstenedione, testosterone, and serum cortisol levels. Theinitial analysis of PD variables was an examination of the groupedsubject data for each biomarker, expressed as a mean percent change frompredose levels for the two active dosing conditions relative to theplacebo condition. The data for mean 17-OHP and ACTH levels throughoutthe 24-hour postdose period are provided in FIG. 5.

Consistent and clinically meaningful reductions from predose levels ofboth 17-OHP and ACTH were observed throughout the postdose periodfollowing administration of NBI-77860 relative to placebo in these CAHpatients. In addition to the group mean data, individual responses wereevaluated and treatment “responders” were conservatively defined asthose subjects with at least a 50% decrease in 17-OHP and ACTH underactive NBI-77860 relative to placebo during the peak morning period.This responder analysis yielded a sizeable responder rate of 50% in thestudy (none of these subjects were responders during the initial placebotreatment period). Furthermore, the 300 mg dose yielded nearly identicaleffects on 17-OHP and ACTH as the 600 mg dose. An example of anindividual subject response for these biomarkers is provided in FIG. 6.

The various embodiments described above can be combined to providefurther embodiments. All U.S. patents, U.S. patent applicationpublications, U.S. patent applications, foreign patents, foreign patentapplications and non-patent publications referred to in thisspecification and/or listed in the Application Data Sheet, includingU.S. Provisional Application Ser. No. 61,929,941, filed Jan. 21, 2014;U.S. Pat. No. 61,981,033, filed Apr. 17, 2014; and 62/069,155, filedOct. 27, 2014, are incorporated herein by reference, in their entirety.Aspects of the embodiments can be modified, if necessary to employconcepts of the various patents, applications and publications toprovide yet further embodiments.

These and other changes can be made to the embodiments in light of theabove-detailed description. In general, in the following claims, theterms used should not be construed to limit the claims to the specificembodiments disclosed in the specification and the claims, but should beconstrued to include all possible embodiments along with the full scopeof equivalents to which such claims are entitled. Accordingly, theclaims are not limited by the disclosure.

What is claimed is:
 1. A method of treating Congenital AdrenalHyperplasia (CAH), said method comprising administering to a subject inneed thereof already being treated with a glucocortocoid, an effectiveamount of a CRF₁ receptor antagonist, wherein the CRF₁ receptorantagonist is4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(SSR-125543), or a pharmaceutically acceptable salt thereof.
 2. Themethod of claim 1, wherein the glucocorticoid is hydrocortisone.
 3. Themethod of claim 1, wherein the glucocorticoid is prednisone.
 4. Themethod of claim 1, wherein the glucocorticoid is prednisolone.
 5. Themethod of claim 1, wherein the glucocorticoid is dexamethasone.
 6. Themethod of claim 1, further comprising administering a salt-wasting,mineralocorticoid to the subject.
 7. The method of claim 6, wherein thesalt-wasting, mineralocorticoid is fludrocortisone.
 8. The method ofclaim 1, wherein the dose of the glucocorticoid is decreased by 10% ormore following administration of the CRF₁ receptor antagonist.
 9. Themethod of claim 1, wherein the dose of the glucocorticoid is decreasedby 15% or more following administration of the CRF₁ receptor antagonist.10. The method of claim 1, wherein the dose of the glucocorticoid isdecreased by 20% or more following administration of the CRF₁ receptorantagonist.
 11. The method of claim 1, wherein the dose of theglucocorticoid is decreased by 30% or more following administration ofthe CRF₁ receptor antagonist.
 12. The method of claim 1, wherein thedose of the glucocorticoid is decreased by 40% or more followingadministration of the CRF₁ receptor antagonist.
 13. The method of claim1, wherein the dose of the glucocorticoid is decreased by 50% or morefollowing administration of the CRF₁ receptor antagonist.
 14. The methodof claim 1, wherein the CAH is classical CAH.
 15. The method of claim 1,wherein the CAH is caused by 21-α hydroxylase deficiency.
 16. The methodof claim 1, wherein the CAH is caused by 11β-hydroxylase deficiency. 17.The method of claim 1, wherein the subject has a mutation in the CYP21A2gene located on chromosome 6p21.
 18. The method of claim 1, wherein thesubject does not have a mutation of the 11β-hydroxylase gene CYP11B1(11β-OH CAH).
 19. The method of claim 1, wherein the CRF₁ receptorantagonist is administered at bedtime.
 20. The method of claim 1,wherein the CRF₁ receptor antagonist is4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(S SR-125543).
 21. The method of claim 1, wherein4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(SSR-125543), or a pharmaceutically acceptable salt thereof, isadministered in the form of a liquid formulation.
 22. The method ofclaim 1, wherein4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(SSR-125543), or a pharmaceutically acceptable salt thereof, isadministered in the form of a solid formulation.
 23. The method of claim1, wherein4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(SSR-125543), or a pharmaceutically acceptable salt thereof, isadministered in the form of a semi-solid formulation.
 24. The method ofclaim 1, wherein4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(SSR-125543), or a pharmaceutically acceptable salt thereof, isadministered in the form of a tablet, powder, granule or capsule. 25.The method of claim 24, wherein4-(2-chloro-4-methoxy-5-methylphenyl)-N-[(1S)-2-cyclopropyl-1-(3-fluoro-4-methylphenyl)ethyl]-5-methyl-N-(2-propyn-1-yl)-2-thiazolamine(SSR-125543), or a pharmaceutically acceptable salt thereof, isadministered in the form of a capsule.
 26. The method of claim 1,wherein the subject is an adult.
 27. The method of claim 1, wherein thesubject is a child.
 28. The method of claim 1, wherein the subject is afemale.